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El. knyga: Guidelines for Investigating Process Safety Incidents

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  • Formatas: PDF+DRM
  • Išleidimo metai: 08-May-2019
  • Leidėjas: Wiley-AIChE
  • Kalba: eng
  • ISBN-13: 9781119529149
Kitos knygos pagal šią temą:
Guidelines for Investigating Process Safety IncidentsDidesnis paveikslėlis
  • Formatas: PDF+DRM
  • Išleidimo metai: 08-May-2019
  • Leidėjas: Wiley-AIChE
  • Kalba: eng
  • ISBN-13: 9781119529149
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"This book provides a comprehensive treatment of investing chemical processing incidents. It presents on-the-job information, techniques, and examples that support successful investigations. Issues related to identification and classification of incidents (including near misses), notifications and initial response, assignment of an investigation team, preservation and control of an incident scene, collecting and documenting evidence, interviewing witnesses, determining what happened, identifying root causes, developing recommendations, effectively implementing recommendation, communicating investigation findings, and improving the investigation process are addressed in the third edition. While the focus of the book is investigating process safety incidents the methodologies, tools, and techniques described can also be applied when investigating other types of events such as reliability, quality, occupational health, and safety incidents"--

This book provides a comprehensive treatment of investing chemical processing incidents. It presents on-the-job information, techniques, and examples that support successful investigations. Issues related to identification and classification of incidents (including near misses), notifications and initial response, assignment of an investigation team, preservation and control of an incident scene,  collecting and documenting evidence, interviewing witnesses, determining what happened, identifying root causes, developing recommendations, effectively implementing recommendation, communicating investigation findings, and improving the investigation process are addressed in the third edition.

While the focus of the book is investigating process safety incidents the methodologies, tools, and techniques described can also be applied when investigating other types of events such as reliability, quality, occupational health, and safety incidents.
Preface xxv
Acknowledgments xxvii
Acronyms And Abbreviations xxix
1 Introduction 1(12)
1.1 Building on the Past
1(1)
1.2 Investigation Basics
2(3)
1.2.1 The First Step
2(2)
1.2.2 The Second Step
4(1)
1.2.3 The Third Step
4(1)
1.2.4 The Fourth step
4(1)
1.2.5 The Fifth Step
5(1)
1.2.6 The Sixth Step
5(1)
1.3 Who Should Read This Book?
5(1)
1.4 The Guideline's Objectives
6(1)
1.5 The Guideline's Content and Organization
6(5)
1.6 The Continuing Evolution of Incident Investigation
11(2)
2 Overview Of Chemical Process Incident Causation 13(13)
2.1 Stages of a Process-Related Incident
14(4)
2.1.1 Three Phase Model of Process-Related Incidents
14(1)
2.1.2 Event Tree
14(2)
2.1.3 Swiss Cheese Model
16(1)
2.1.4 Importance of Latent Failures
17(1)
2.2 Key Causation Concepts
18(6)
2.2.1 Loss of Containment or Energy
18(2)
2.2.2 Management System Failure
20(1)
2.2.3 Human Factors
21(1)
2.2.4 Multiple Causation
22(1)
2.2.5 Events vs Root Causes
22(1)
2.2.6 Controlling Risk
23(1)
2.3 Summary
24(2)
3 An Overview Of Investigation Methodologies 26(21)
3.1 History of Investigation Methodologies and Tools
29(5)
3.1.1 One-on-One Interview
29(1)
3.1.2 Brainstorming
29(1)
3.1.3 What If Analysis
30(1)
3.1.4 5-Whys
30(1)
3.1.5 Process of Elimination
31(1)
3.1.6 Timelines
31(1)
3.1.7 Sequence Diagrams
31(2)
3.1.8 Predefined Trees
33(1)
3.2 Tools for Use in Preparation for Root Cause Analysis
34(3)
3.2.1 Timelines
34(1)
3.2.2 Sequence Diagrams
35(1)
3.2.3 Scientific Method
35(1)
3.2.4 Causal Factor Identification
36(1)
3.3 Structured Root Cause Analysis Methodologies
37(6)
3.3.1 Checklists
37(1)
3.3.2 Predefined Trees
38(1)
3.3.3 Team-Developed Logic Trees
39(4)
3.4 Selecting an Appropriate Methodology
43(4)
3.4.1 Methodologies Used by CCPS Members
46(1)
4 Designing An Incident Investigation Management System 47(32)
4.1 System Considerations
49(9)
4.1.1 An Organization's Responsibilities
49(2)
4.1.2 Workforce Responsibilities
51(2)
4.1.3 Role of the Management System Developers
53(1)
4.1.4 Integration with Other Functions and Teams
54(1)
4.1.5 Involvement by Regulatory Agencies
55(3)
4.2 Typical Management System Topics
58(16)
4.2.1 Classifying Incidents
58(1)
4.2.2 Specifying and Managing Documentation
59(1)
4.2.3 Legal Considerations
60(3)
4.2.4 Describing Team Organization and Functions
63(1)
4.2.5 Electronic Process Data and Control Systems
64(1)
4.2.6 Defining Training Requirements
65(4)
4.2.7 Emphasizing Root Causes
69(1)
4.2.8 Fostering a Blame-Free Policy
70(1)
4.2.9 Developing Recommendations
70(1)
4.2.10 Recommendation Responsibilities
71(1)
4.2.11 Implementing the Recommendations and Follow-up Activities
72(1)
4.2.12 Providing a Template for Formal Reports
73(1)
4.2.13 Management System Review and Approval
73(1)
4.2.14 Planning for Continuous Improvement
73(1)
4.3 Management System
74(5)
4.3.1 Initial Implementation-Training
75(1)
4.3.2 Developing a Specific Investigation Plan
75(4)
5 Initial Notification, Classification And Investigation Of Process Safety Incidents 79(17)
5.1 Internal Reporting
79(2)
5.2 Incident Classification
81(9)
5.2.1 Severity Classification
82(7)
5.2.2 Local Jurisdiction
89(1)
5.2.3 Other Options for Establishing Classification Criteria
89(1)
5.3 Incident Notification
90(2)
5.3.1 Corporate Notification
90(1)
5.3.2 Agency Notification
91(1)
5.3.3 Other Stakeholder Notification
91(1)
5.3.4 Other Notifications
92(1)
5.4 Type of Investigation
92(2)
5.4.1 Which Investigation System to Use?
92(1)
5.4.2 Investigation Approach
93(1)
5.5 Summary
94(2)
6 Building And Leading An Incident Investigation Team 96(14)
6.1 Team Approach
96(1)
6.2 Advantages of the Team Approach
97(1)
6.3 Leading a Process Safety Incident Investigation Team
98(2)
6.4 Potential Team Composition
100(4)
6.5 Building a Team for a Specific Incident
104(2)
6.5.1 Composition and Size of Investigation Team
104(2)
6.6 Team Activities
106(2)
6.7 Summary
108(2)
7 Witness Management 110(27)
7.1 Overview
110(3)
7.1.1 Witness Issues Following a Major Occurrence
111(1)
7.1.2 Investigation Team Priorities for Managing Witnesses
112(1)
7.2 Identifying Witnesses
113(2)
7.3 Witness Interviews
115(19)
7.3.1 Human Factors Related to Interviews
115(3)
7.3.2 Collecting Information from Witnesses
118(2)
7.3.3 Initial Witness Statements
120(1)
7.3.4 Conducting the Interview
121(13)
7.4 Conducting Follow-up Activities
134(1)
7.5 Conducting Follow-up Interviews
135(1)
7.6 Reliability of Witness Statements
135(1)
7.7 Summary
135(2)
8 Evidence Identification, Collection And Management 137(41)
8.1 Overview
137(7)
8.1.1 Developing a Specific Plan
138(1)
8.1.2 Investigation Environment Following a Major Occurrence
139(2)
8.1.3 Priorities for Managing an Incident Investigation Team
141(3)
8.2 Sources of Evidence
144(12)
8.2.1 Types of Sources
144(3)
8.2.2 Physical Evidence and Data
147(2)
8.2.3 Paper Evidence and Data
149(3)
8.2.4 Electronic Evidence and Data
152(1)
8.2.5 Position Evidence and Data
153(3)
8.3 Evidence Gathering
156(12)
8.3.1 Initial Site Visit
157(2)
8.3.2 Identifying and Documenting Evidence
159(3)
8.3.3 Tools and Supplies
162(2)
8.3.4 Photography and Video
164(4)
8.4 Timelines and Sequence Diagrams
168(8)
8.4.1 Constructing a Timeline
168(6)
8.4.2 Constructing a Sequence Diagram
174(2)
8.5 Summary
176(2)
9 Evidence Analysis And Causal Factor Determination 178(25)
9.1 Scientific Method
178(3)
9.2 Confirmation Bias
181(1)
9.3 Evidence Analysis
181(6)
9.3.1 Data Organization - Timelines
182(1)
9.3.2 Use of Protocols
182(2)
9.3.3 Mechanical Failure Analysis
184(3)
9.3.4 Advanced Data Systems
187(1)
9.4 Hypothesis Formulation
187(3)
9.4.1 Fact/Hypothesis Matrix
188(2)
9.5 Hypothesis Testing
190(3)
9.5.1 Engineering Analysis
190(1)
9.5.2 Computational Modeling
191(1)
9.5.3 Reconstruction
191(1)
9.5.4 Test the Items under Simulated Conditions
192(1)
9.5.5 Testing of Human Input/Performance
192(1)
9.6 Select the Final Hypothesis
193(9)
9.6.1 Causal Factor Identification
193(5)
9.6.2 Causal Factor Charting
198(2)
9.6.3 Developing a Causal Factor Chart
200(2)
9.7 Summary
202(1)
10 Determining Root Causes-Structured Approaches 203(58)
10.1 Concept of Root Cause Analysis
203(3)
10.2 Case Histories
206(2)
10.3 Methodologies for Root Cause Analysis
208(6)
10.3.1 5 Whys Technique
208(4)
10.3.2 Structured Root Cause Determination
212(2)
10.4 Root Cause Determination Using Logic Trees
214(5)
10.4.1 Gather Evidence and List Facts
215(1)
10.4.2 Timeline Development
215(1)
10.4.3 Logic Tree Development
215(4)
10.5 Building a Logic Tree
219(16)
10.5.1 Choosing the Top Event
220(1)
10.5.2 Logic Tree Basics
220(8)
10.5.3 Example-Chemical Spray Injury
228(4)
10.5.4 What to Do if the Process Stalls
232(1)
10.5.5 Guidelines for Stopping Tree Development
232(3)
10.6 Example Applications
235(7)
10.6.1 Fire and Explosion Incident-Fault Tree
235(4)
10.6.2 Data-Driven Cause Analysis
239(2)
10.6.3 Logic Tree Summary
241(1)
10.7 Root Cause Determination Using Predefined Trees
242(4)
10.7.1 Scenario Determination
244(1)
10.7.2 Causal Factors
244(1)
10.7.3 Predefined Tree
245(1)
10.8 Using Predefined Trees
246(10)
10.8.1 Predefined Tree Methodology
247(1)
10.8.2 Example-Environmental Incident
248(7)
10.8.2 Quality Assurance
255(1)
10.8.3 Predefined Tree Summary
255(1)
10.9 Checklists
256(2)
10.9.1 Use of Checklists
257(1)
10.9.2 Checklist Summary
258(1)
10.10 Human Factors Applications
258(1)
10.11 Summary
259(2)
11 The Impact Of Human Factors 261(17)
11.1 Human Factors Concepts
262(5)
11.2 Incorporating Human Factors into the Incident Investigation Process
267(9)
11.2.1 Human Factors Before and During the Incident
268(1)
11.2.2 Human Factors during the Causal Analysis
269(6)
11.2.3 Human Factors in Developing Recommendations
275(1)
11.2.4 After the Investigation
275(1)
11.3 Other References
276(1)
11.4 Summary
276(2)
12 Developing Effective Recommendations 278(17)
12.1 Key Concepts
278(2)
12.2 Developing Effective Recommendations
280(3)
12.2.1 Team Responsibilities
280(1)
12.2.2 Attributes of Good Recommendations
280(3)
12.3 Types of Recommendations
283(7)
12.3.1 Inherently Safer Design
284(1)
12.3.2 Layers of Protection
285(4)
12.3.3 Commendation/Disciplinary Action
289(1)
12.3.4 The "Further Action Required" Recommendation
289(1)
12.4 The Recommendation Process
290(4)
12.4.1 Select Each Cause
290(1)
12.4.2 Perform a Completeness Test
290(1)
12.4.3 Assessing the Effectiveness
291(1)
12.4.4 Prepare to Present Recommendations
291(2)
12.4.5 Review Recommendations with Management
293(1)
12.4.6 Tracking and Closure of Recommendations
293(1)
12.5 Summary
294(1)
13 Preparing The Final Report 295(19)
13.1 Report Scope
295(1)
13.2 Interim Reports
296(1)
13.3 Writing the Report
297(2)
13.4 Sample Report Format
299(8)
13.4.1 Executive Summary
300(1)
13.4.2 Introduction
301(1)
13.4.3 Background
301(1)
13.4.4 Sequence of Events and Description of the Incident
302(1)
13.4.5 Findings
302(1)
13.4.6 Causal Factors
303(1)
13.4.7 Root Causes
304(1)
13.4.8 Recommendations
304(2)
13.4.9 Noncontributory Factors
306(1)
13.4.10 Attachments or Appendices
306(1)
13.5 Report Review and Quality Assurance
307(3)
13.5.1 Reviewing the Report
307(1)
13.5.2 Avoiding Common Mistakes
308(2)
13.6 Investigation Document and Evidence Retention
310(1)
13.7 Summary
311(3)
14 Implementing Recommendations 314(12)
14.1 Activities Related to Recommendation Implementation
315(2)
14.2 Validation of Effectiveness - Case Studies
317(2)
14.2.1 Nuclear Plant Incident
317(1)
14.2.2 Aircraft Incident
318(1)
14.2.3 Petrochemical Plant Incident
318(1)
14.2.4 Challenger Space Shuttle Incident
318(1)
14.2.5 Typical Plant Incidents
319(1)
14.3 Practical Suggestions for Successful Recommendation Implementation
319(7)
14.3.1 Assigning a Responsible Individual
320(1)
14.3.2 Due Dates and Priorities to Implement Recommendations
320(1)
14.3.3 Challenges to Resolving Recommendations
321(2)
14.3.4 Tracking Action Items
323(1)
14.3.5 Follow-up Verification
323(3)
15 Continuous Improvement For The Incident Investigation System 326(14)
15.1 Regulatory Compliance Review
327(2)
15.2 Investigation Quality Assessment
329(2)
15.3 Causal Category Analysis
331(3)
15.4 Review of Near-Miss Events
334(1)
15.5 Recommendations Review
334(2)
15.6 Investigation Follow-up Review
336(1)
15.7 Key Performance Indicators
337(1)
15.8 Summary
338(2)
16 Lessons Learned 340(17)
16.1 Various Sources of Learning from Incidents
341(2)
16.1.1 Internal Sources
341(1)
16.1.2 External Sources
341(2)
16.1.3 Cross-Industry
343(1)
16.2 Identifying Learning Opportunities
343(2)
16.3 Sharing and Institutionalizing Lessons Learned
345(2)
16.4 Senior Management - Incident Sharing and Commitment
347(1)
16.5 Examples of Sharing Lessons Learned
348(7)
16.5.1 Creating a Process Safety Alert from a Case Study
348(2)
16.5.2 Safety Newsletter
350(5)
16.5.3 Videos of Incidents
355(1)
16.5.4 Detailed Incident Reports and Databases
355(1)
16.6 Summary
355(2)
Appendix A. Photography Guidelines For Maximum Results 357(5)
Appendix B. Example Protocol - Checking Position Of A Chain Valve 362(4)
Appendix C. Process Safety Events Leveling Criteria 366(2)
Appendix D. Example Case Study 368(30)
Appendix E. Quick Checklist For Investigators 398(6)
Appendix F. Evidence Preservation Checklist - Prior To Arrival Of The Investigation Team 404(2)
Appendix G. Guidance On Classifying Potential Severity Of A Loss Of Primary Containment 406(10)
Glossary 416(11)
References 427(10)
Index 437
The Center for Chemical Process Safety (CCPS) was founded in 1985 to develop technology and management practices that mitigate or eliminate process safety incidents in the chemical and petrochemical industries. Since that time, CCPS has published more than 100 books and held dozens of international conferences, each representing the most advanced thinking in process safety. CCPS is supported by the contributions and voluntary participation of more than 200 companies globally. CCPS is also the world's largest provider of undergraduate engineering curriculum materials through its SAChE program, with more than 160 universities participating from around the world.
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